Purchased Referred Care - Navajo Health Foundation

Purchase Referred Care

(928) 755 – 4898

Purchased Referred Care (PRC) is a program that helps eligible American Indian patients get the necessary special health care service that is not available at Sage Memorial Hospital (SMH) or any IHS/638 facility. PRC receives a fixed amount of funding to help pay for referred specialty medical services, hospital admissions, and emergency care when the Direct Care is not available at an IHS/638 facility.

WHAT IS THE DIFFERENCE BETWEEN DIRECT CARE AND PURCHASED/REFERRED CARE?

DIRECT CARE If the patient is an American Indian/Alaskan Native from a federally recognized Tribe, the patient can get direct health care at most IHS or Tribal Health programs, without a cost to the patient.

PURCHASED/REFERRED CARE If the patient needs healthcare that an IHS/638 program cannot provide and a SMH medical provider has referred the patient to an outside specialty, this is called referred care.

Medical referrals are a request for medical services; they do not guarantee payment of medical services.

Click here to download PRC Application

PRC REQUIREMENTS

American Indians/Alaskan Natives (AI/AN) need to be aware of the following requirements when referred for medical services, hospital admission, and emergency care when an IHS or Navajo Area healthcare facility is unable to meet these healthcare needs. PRC eligibility will be determined by a PRC Specialist based upon federal regulations and a referral from your primary care provider

All patients must notify PRC of going to the Emergency Room or Urgent Care within 72 hours to be eligible for PRC coverage. For Elders, aged 60 and over, notification must be made within 30 days.

All patients seeking PRC funds must provide a current PRC Service application (updated annually), all eligibility documents, and are required to apply for alternate resources for care.

PRC is not an insurance and is not an entitlement program. Not everyone is eligible for PRC. PRC is considered the payor of last resort and the use of all other resources available and accessible to the patient must be utilized first.

ELIGIBILITY CRITERIA

All eligibility requirements must be met…

Indian Decent
Residency
Medical Priority

You must be receiving care for a condition that meets the SMH Medical Priority and Necessity guidelines.

Alternate Resources

PRC is considered Payor of Last Resort and secondary to all other alternate health resources, i.e., Medicare, Medicaid, private insurance, etc.

You must apply for and use any other alternate health care resources available to you before PRC funds can assist with the payment of any Non-IHS provider/facility health care bills. This includes: Medicare, State Medicaid (AHCCCS) or private insurance.

Notification / Prior Authorization

PRC must be properly notified when a patient has or will be obtaining medical services from a non-lHS provider/facility:

Notification occurs after the emergency service.

Emergent- PRC must be notified within 72 business hours from the time the patient received treatment or was admitted. For an elderly over age 60 years old, the notification timeline is within 30 business days.

PROOF OF RESIDENCY

Documents acceptable for proof of residency must include the patient’s name and physical address and be dated within the last 60 days.

NOTE: Your name, address and current date must be visible, and it must be a current document from within the past 60 days.

You may submit your documents in a few ways:

In-person at the PRC office. Location is next to Outpatient, doorway to the right prior to the Pharmacy (look for signs)
Faxing to the PRC office 928-755-4758

Provide one of the following to show your current physical address

Valid State driver’s license or State Issued ID card	Employment check stub received within the past thirty (30) days showing address and withholding taxes.	Utility Bill: electric, gas, water, cable, cell phone, or telephone issued within the last sixty (60) days.
Tribal ID card with a photo	Homeowner’s or renter’s insurance policy	Rental or lease agreement
U.S. Passport	Mortgage Statement	Rental payment receipt
Voter’s registration card	Property Tax Bill	Settlement Papers
Valid college ID with a photo	Property Deed	Marriage License
Other Tribal government issued documents.

72 HR NOTIFICATION

Emergency Situations

For after-hours urgent or severe medical problems, go directly to the hospital and notify PRC within 72 hours. Tribal elders aged 60 and over are allowed 30 days to notify PRC.
All ER and Urgent Care visits require notification even with an active referral for care for a condition that is related to the emergency.
* Notification is not a guarantee of payment*
When seeking emergency care outside of the Sage Memorial Hospital PRC Delivery Area, follow the same guidelines above.
- Obtain information regarding the facility you went to and provide that information when you notify SMH PRC of the visit.
- Request records be sent to your Primary Care Provider (PCP) at SMH
You may notify PRC by calling the number below or submitting your notification online:
- CALL:
  - Notification must be provided within 72 hours of discharge or admission by calling the Purchased/Referred Care Department directly at (928) 755-4898.
  - If you are calling after business hours, please leave a message with the following information:
    - Patient Name/Date of Birth
    - Phone Number
    - Date of Emergency / Date of Appointment / Date of Admission-Discharge
    - Facility where you were seen
    - The reason or diagnosis
    - Mode of transportation
- ONLINE FORM

CLICK HERE - To access 72 hour notification form

ALTERNATE RESOURCES

Purchased Referred Care is considered the “payor of last resort”. The use of alternate resources is required when such resources are available and accessible to the individual, such as:

Medicare A and B
State Medicaid (AHCCCS/ALTCS)
State or other federal health programs
Private insurance, etc.
Indian Health Services (IHS) or Tribal health facilities
Workman’s compensation

For assistance with applying for alternate resources, please contact your Healthcare Management Department at (928) 755-4636 or (928) 755-4827.

NEMT (TRANSPORTATION)

If you need AHCCCS Non-Emergent Medical Transportation (NEMT), you must contact PRC with your appointment date and time at least 14 days before your appointment date.

It can take AHCCCS up to 14 days to process the request once we fax the request to them.

PRC does not approve/deny NEMT Transportation, PRC faxes the request as a courtesy.
PRC does not schedule or coordinate rides for patients with the NEMT drivers; that is the patient responsibility.
AHCCCS determines approval/denial and does not give that information to PRC.
The NEMT Transport Company / Dispatch obtains that information from AHCCCS directly.

Contact Purchased/Referred Care

Navajo Health Foundation – Sage Memorial Hospital Purchased/Referred Care
Post Office Box 457
SR 264, HWY 191
Ganado, AZ 86505
Telephone: (928) 755-4898
Fax: (928) 755-4815

Purchased/Referred Care